CASE

A 47 year-old man presents to your office for a follow-up visit. He was seen 3 weeks ago for
an upper respiratory infection and noted incidentally to have a blood pressure of 164/98 mm
Hg . he vaguely remembered being told in the past that his blood pressure was “borderline” .
he feels fine , has no complaints , and his review of systems is entirely negative. He does not
smoke cigarettes, drinks “ a couple of beers on the weekends”, and does not exercise
regularly. He has a sedentary job. His father died of a stroke at the age of 69 years. His
mother is alive and in good health at the age of 72 years. He has two siblings and is not aware
of any chronic medical issues that they have. In the office today, his blood pressure is 156/96
mmHg in his left arm and 152/98 mmHg in the right arm. He is afebrile , his pulse is 78 bpm
, respiratory rate 14 breaths per minute, he is 70 in tall, and weighs 210 Ib . a general physical
examination is normal.

KEYWORD
. A 47 year-old man

. Upper respiratory infection

. Blood pressure of 164/98 mm Hg

. Blood pressure was “borderline”

. does not exercise regularly

. His father died of a stroke

. 156/96 mmHg in his left arm (today)

. 152/98 mmHg in the right arm (today)

PROBLEM
Mr. A has high blood pressure
TAKING NOTE 1
Surename : A

Age : 47 years

Sex : man

Occupation : Sedentary job

Present complaint : follow up visit

O/E

General condition : 70 in tall, 210 LB

ENT : NAD

RS : RR : 14 breaths/minute

CVS : P : 78 bpm blood pressure : 156/96 mmHg in his left arm

152/98 mmHg in the right arm

HS: normal

GUS : -

CNS : -

Immediate past history : he was seen 3 weeks ago for an upper respiratory infection and noted
incidentally to have a blood pressure of 164 / 98 mmHg . his father died of a stroke at the age
of 69 years

Diagnosis : hypertension

Management : kaptopril, tiazid, beta blocker, diuretics

Taking note 2
System Complaint No complaint Order
ENT √
RS √
CVS √ 156/96 mmHg
(Left Arm)
152/98 mmHg
(Right Arm)
GIS √
GUS √
CNS √
Psychiatric √

Conversation
D : Good Morning, My name is dr.Octopus

P : Morning dok

D : What is your name ?

P : My name is Mr.A

D : How old are you ?

P : 47 years old

D : what is your address ?

P : Jl.Pramuka Kemiling, Bandar Lampung

D : What is you occupation ?

P : i have sedentary job

D : what brought you along today ?

P : I want to follow up my body

D : what do you feel about your body ?

P : 3 weeks ago . I was seen for upper respiration and noted incidentaly to have a blood
pressure of 164/98 mmHg

D : and then ?

P : i remember in the past that my blood preasurre was “border line”

D : How about habituation ? are you smoker ?

P : No, i am not

D : Do you like drink an alkohol ?

P : I drinks “a couple of beers on the weekend”

D : Do you have any exercise regularly ?

P : No, I dont

D : In your family, do they have same problem like you ? can you tell me ?

P : My Father have died because stroke at the age of 69 years . My mother and my
siblings is normal

D : Oke. Thank you . Its time to fisic excamination .

P : Oke lets go dok

D :The result of your follow up is something wrong with your blood presurre its higher
than normal blood pressure.